TIDEWATER EMERGENCY MEDICAL SERVICES COUNCIL, INC. PREHOSPITAL DRUG AND IV INCIDENT REPORT Incident Description NAME/TITLE OF PERSON REPORTING: _________________________________________________________ AGENCY/HOSPITAL OF REPORTING PERSON___________________________________________________ DATE/TIME: _________________ BOX NUMBER(S):_________ IV BOX __ DRUG BOX__ EMS AGENCY EXCHANGING:____________________________________ EMS UNIT: __________________ LAST PHARMACY RESTOCKING: _______________________________________________ DESCRIPTION OF INCIDENT: _________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ SIGNATURE: _________________________________________________ |
EMS Council Action RECEIVED BY:_____________________________ DATE RECEIVED: ______________________________ ACTION TAKEN: __________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Agency Action and Follow-up DATE RECEIVED: ________________________________ CORRECTIVE ACTION TAKEN:_______________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ SIGNATURE: ____________________________________ PRINT NAME: ___________________________________ TITLE: __________________________________ DATE: __________________________________________ ORIGINAL: MEDICAL DIRECTOR COPY 1: EMS COUNCIL COPY 2: REPORTING AGENCY/HOSPITAL |